Health inspection·July 28, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Intervention and care plan updated: When repositioning her (R57) make sure she (R57) is in center of her bed. Maintenance to check brakes on bed and mattress (air-mattress) for proper functioning. On 7/27/23 at 1:32 pm, R57's was seated in her wheelchair. R57 had a left above knee amputation. R57 had an air mattress on her bed. R57 stated the following: When I (R57) fell out of bed, two CNA's (unidentified Certified Nursing Assistants) came in and changed (provided perineal care) me (R57). I told them (unidentified CNA's) at that time, my mattress was loosing air. They positioned me, facing the wall after changing me, and left the room. It was about a half hour later the mattress had lost more air. I rolled out of bed and hit the floor. The bed brakes were not working properly. I wasn't hurt, just achy for a day or two. The rest of the night I had to sleep in my recliner. Maintenance came in and looked at the brakes. Later that day, I got this new air mattress (points to her bed). On 7/27/23 at 1:40 pm V7, ADON stated The CNA's should have reported to the nurse (unidentified) immediately (per R57 interview, during incontinence care 30 minutes before R57's fall 4/5/23) that her (R57's) air mattress was deflating. We did get her a new mattress that same day. On 7/27/23 at 2:20 pm V15, Assistant Maintenance worker stated V15 did checked the brakes after R57 fall 4/5/23, but knew nothing about the mattress. V15 also stated There was nothing wrong with (R57's) brakes. The CNA (unidentified) just forgot to lock them (bed brakes). 2.) R17's admission Record face sheet dated 7/28/23 documents the following diagnoses: Chronic Obstructive Pulmonary Disease Unspecified, Chronic Respiratory Failure With Hypoxia, Chronic Respiratory Failure With Hypercapnia, Heart Failure Unspecified, Low Back Pain Unspecified, Neuralgia (nerve pain), Neuritis (nerve inflammation) Unspecified and Anxiety. On 7/25/23 at 3:35 pm, R17 sat on the side of R17's bed. R17 had an oxygen nasal cannula actively administering four liters of oxygen via a concentrator. The oxygen concentrator was positioned just inside R17's bathroom. R17's oxygen tubing had an extension approximately 25 feet in length. R17's oxygen tubing lay on the floor, and extended approximately 18 feet from R17 oxygen concentrator in the bathroom, to R17's bed. The tubing had twisted areas that coiled at the side of R17's bed, under and around R17's feet, as R17 sat on the side of the bed. R17 stated This (oxygen tubing) has always been a problem. My room is small and the tubing is long. I like to get all around the room with it (oxygen). They would have to change the tank (E-tank portable oxygen, wheeled caddy) several times a day, if I had to use that (E-tank) to keep the tubing (oxygen) off the floor. The tank (E-tank) does not have all the extra tubing. R17 ambulated to the bathroom from his bed. R17 stated I (R17) was given this bag (attached to the oxygen concentrator in the bathroom which contained excess concentrator electrical cord) but it is too small for all this tubing. R17 ambulates back to R17's bed, stepping repeatedly over the coiled and twisted oxygen tubing. R17 picks up some of the tubing and attempts to untwist the tubing. R17 then states It would be real nice if maintenance could figure out something to fix this tubing. I haven't fallen yet, but I don't want to either. On 7/27/23 at 3:40 pm V9, Registered Nurse (RN) acknowledged R17 extensive oxygen tubing was strung across R17's floor and into R17's bathroom where R17's oxygen concentrator sat. V9 stated The oxygen tubing is a trip hazard and is not sanitary. R17's Minimum Data Set, dated [DATE] documents R17 has a Brief Interview of Mental Status score of 15 out of a possible 15, which indicates R17 has no cognitive impairment and requires supervision during ambulation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145930 If continuation sheet Page 2 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Pontiac Nursing Home 1225 South Ewing Drive Pontiac, IL 61764 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 R17's Care Plan dated as initiated 1/14/18 and revised 7/26/23 documents the following: Level of Harm - Minimal harm or potential for actual harm (R17) is at risk for falls r/t (related to) possible side effects of psychotropic medications and ambulates independently pulling portable O2 (oxygen). Residents Affected - Few R17's same Care Plan documents an intervention as follows: He (R17) needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light. The facility policy Fall Prevention Program dated as revised 11/21/17 documents the following: Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Guidelines include: Fall/safety interventions may include but are not limited to: Bullet number four *The bed locks will be checked to assure they are in the locked position at all times. and bullet number 15 * Malfunctioning equipment will be immediately reported to maintenance for repair or removed from service, i.e. bed locks, side rails, and grab bars. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145930 If continuation sheet Page 3 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Pontiac Nursing Home 1225 South Ewing Drive Pontiac, IL 61764 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to obtain a physician's order for oxygen administration and failed to store oxygen tubing in a sanitary manner for one of two residents (R63) reviewed for oxygen in the sample list of 28. Residents Affected - Few Findings Include: The Oxygen and Respiratory Equipment policy dated 1/7/19 documents oxygen nasal cannula tubing should be stored in a clear plastic bag when not in use. R63's Medical Diagnoses List dated July 2023 documents R63 is diagnosed with Chronic Obstructive Pulmonary Disease, Acute Respiratory Failure, and Congestive Heart Failure. R63's Physician Order Sheet (POS) dated July 2023 documents R63 is prescribed oxygen at two liters via nasal cannula for mild Dyspnea or oxygen saturation less than 88 percent. This order was not added until 7/28/23. On 7/25/23 at 2:04 PM R63's oxygen tubing was left hanging across the bedside dresser drawer with the cannula touching the floor. On 7/27/23 at 11:15 AM R63's oxygen tubing was left hanging across the bedside dresser drawer with the cannula touching the floor. On 7/27/23 at 11:27 AM V17 Registered Nurse (RN) stated R63 only wears her oxygen at night and confirmed the tubing should be stored in a clear plastic bag when not in use. On 7/27/23 at 4:00 PM V2 Director of Nurses (DON) confirmed residents should have a physician order for oxygen and should also store oxygen tubing in a bag and not leave the tubing, hanging on furniture when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145930 If continuation sheet Page 4 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Pontiac Nursing Home 1225 South Ewing Drive Pontiac, IL 61764 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to obtain a physician order for dialysis treatment and failed repeatedly to monitor the dialysis catheter site and dressings for two of two residents (R29, and R58) reviewed for Dialysis on the sample list of 28. Residents Affected - Few Findings Include: The Dialysis Monitoring and Observation policy dated 2/13/18 documents if the resident has a catheter for dialysis the nurse should assess the catheter site for any signs of drainage and assess the condition of the catheter dressing every shift. 1. R29's Medical Diagnoses list dated July 2023 documents R29 is diagnosed with End Stage Renal Disease. R29's July 2023 Physician Order Sheet (POS) does not include an order for Hemodialysis or an order for staff to monitor the dialysis catheter site/dressing. On 7/25/23 at 2:16 PM, R29 stated she goes out of the facility for Hemodialysis, three times per week, outside of the facility, and the dialysis staff change her catheter site dressing and flush her dialysis catheter. R29 stated the facility nursing staff do not ever ask to observe her dialysis catheter. 2. R58's Medical Diagnoses list dated July 2023 documents R58 is diagnosed with Chronic Kidney Disease. R58's July 2023 Physician Order Sheet (POS) does not include an order for Hemodialysis or an order for staff to monitor the dialysis catheter site/dressing. On 7/27/23 at 2:16 PM, R58 stated he goes out of the facility for Hemodialysis, three times per week outside of the facility and the dialysis staff change his catheter site dressing and flush his dialysis catheter. R58 stated the facility nursing staff do not ever ask to observe his dialysis catheter. On 7/27/23 at 11:20 AM, V17, Registered Nurse (RN) stated R29 and R58 both go out of the facility for Hemodialysis three times per week. V17 stated there should be a physician's order for dialysis and confirmed the facility nurses do not assess R29 or R58's dialysis catheter sites. V17 stated only the dialysis facility does anything with the catheter sites, and she was not even certain what kind of dialysis access V29 or V58 have. On 7/27/23 at 12:21 PM, V16, Dialysis Clinic Manger stated both R29 and R58 have right upper chest central venous catheters for dialysis use. V16 stated the catheters are flushed and dressings changed at the dialysis center however, the facility nursing staff should be monitoring the catheter site and ensuring the dressing stays dry and intact. V16 stated the facility should also be monitoring for signs and symptoms of infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145930 If continuation sheet Page 5 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Pontiac Nursing Home 1225 South Ewing Drive Pontiac, IL 61764 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 Level of Harm - Minimal harm or potential for actual harm Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Based on interview and record review, the facility failed to provide the necessary behavioral health care services for one of one residents (R48) reviewed for behavioral health on the sample list of 28. Residents Affected - Few Findings include: On 7/26/23 at 10:05 AM, V12 (R48's family member) stated R48 gets physical with the staff, actually hitting a staff member last week, and has depression due to loosing R48's spouse last year. V12 also stated that back in the day, V12 believes R48 had a diagnosis of Bipolar but it was not really discussed. V12 explained that V12 was called in today by the staff due to R48 refusing care. R48's ongoing Diagnosis Listing documents diagnoses of : Unspecified Dementia without behavioral disturbances, psychotic disturbance, or mood disturbance, and anxiety. R48's MDS (Minimum Data Set) dated 7/5/23 documents R48 exhibits physical behaviors 1-3 times a week, verbal behaviors 4-6 times a week, rejects care and wanders 1-3 times a week and receives antipsychotic and antidepressant medications daily and antianxiety medications 6 out of the last 7 days. R48's July 2023 Physician Orders document R48 receives the following medications: Lorazepam {Antianxiety} 0.5 mg (milligrams) BID (twice a day), Seroquel {Antipsychotic}50 mg BID, and Sertraline {Antidepressant} 50 mg BID. R48's Care Plan dated 4/10/23 documents R48 is administered Psychotropic Medications for anxiety with repetitive movements and repetitive anxious complaints, and depression with crying and tearfulness. R48's behavior tracking from April - July 2023 documents multiple occurrences of yelling/screaming, kicking/hitting, abusive language, threatening behaviors, rejection of care, and repeated movements. On 7/27/27 at 10:09 AM, V5, SSD (Social Service Director) stated the facility uses a behavioral health provider that comes to the facility weekly. V5 explained R48 has not been seen by behaviors health yet due to when R48 was admitted to the facility, it was for a short term rehabilitation stay, but R48 is now considered a long term placement as of 4/23/23, and should have been put on the list to be seen by behavioral health at that time. V5 stated R48 was missed/overlooked because of a change in the facility admission Coordinators around that time. V5 stated that V5 was just told this morning, by V2 DON (Director of Nursing) to make a referral to behavioral health for R48. On 7/27/23 at 11:13 AM, V13, Nurse Consultant stated when a resident has behaviors, the facility is to have them seen by behaviors health services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145930 If continuation sheet Page 6 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Pontiac Nursing Home 1225 South Ewing Drive Pontiac, IL 61764 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review, the facility failed to assess for psychotropic medications to ensure appropriate indications for the use of psychotropic medications, and obtain consent repeatedly for 33 days, for psychotropic medications for one of two residents (R48) reviewed for psychotropic medications on the sample list of 28. Findings Include: R48's ongoing Diagnosis Listing documents the following diagnoses: Unspecified Dementia without behavioral, psychotic, mood disturbances or anxiety, and anxiety. R48's July 2023 Physician Order Sheet documents the following medication orders: Lorazepam {Antianxiety} 0.5 MG (milligrams) - Give 1 tablet by mouth, BID (two times a day) for anxiety. Seroquel {Antipsychotic} 50 MG - Give 50 mg, by mouth BID for Unspecified Dementia, Unspecified Severity, without Behavioral Disturbances, Psychotic Disturbances, Mood Disturbance, and Anxiety. Sertraline {Antidepressant} 50 MG - Give 50 mg, by mouth BID for depression R48's Discontinued Medication List dated July 2023 documents the following: Seroquel 50 MG - give 50 mg by mouth in the evening from 4/6/23 - 7/14/23. Sertraline 50 mg - Give 50 mg by mouth at bedtime from 4/4/23 - 4/12/23 R48's medical record did not contain a consent for the use of Sertraline, or have a consent signed for use of the Seroquel 50 mg every evening, until 5/9/23, 33 days after it was initiated. R48's medical record also did not contain psychotropic medication assessments. On 7/27/23 at 8:32 AM, V2, DON (Director of Nursing) confirmed R48 has not had any psychotropic medication assessments completed explaining, There should have been one done upon admission due to (R48) admitting with medications, quarterly and with the changes of medications. V2 also stated consents should have been gotten prior to giving the medications but they weren't obtained. V2 also stated the diagnosis for R48's Seroquel is not an appropriate diagnosis for the use of an antipsychotic medication. The facility Psychotropic Medication-Gradual Dose Reduction Policy dated 2/1/18, documents residents will not be given psychotropic drug therapy unless it is necessary to treat a specific or suspected condition as per current standards of practice, and are prescribed at the lowest therapeutic dose to treat such conditions. This policy also documents, psychotropic medication shall not be administered without the informed consent of the resident or the authorized resident representative. On 7/27/23 at 11:13 AM, V13 Nurse Consultant, and V1 Administrator in Training, both stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145930 If continuation sheet Page 7 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Pontiac Nursing Home 1225 South Ewing Drive Pontiac, IL 61764 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 only Psychotropic Medication Policy the facility has is in relation to GDR's (Gradual Dose Reductions). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145930 If continuation sheet Page 8 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Pontiac Nursing Home 1225 South Ewing Drive Pontiac, IL 61764 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to prevent the potential for cross-contamination and food-borne illness, by failing to maintain sanitary food processing equipment, free of grease-like substance, metal fragments, rust and exposed metal. These failures have the potential to affect all 78 residents residing in the facility. Findings include: 1. ) On 7/27/23 at 10:00 am V8, Dietary Manager (DM), V8, DM acknowledged the commercial table-top mounted can opener was rusty, corroded with a brown grease-like buildup in the gears and had metal fragments adhering to the grease- like substance. The same can opener had chipped silver paint off of the tip of the can opener blade, which exposed bare metal. V8, DM stated The can opener is not sanitary and will need to be replaced. 2.) On 7/27/23 at 10:15 am, V8, DM also acknowledged the facility commercial table-top, eight quart mixer had exposed metal and a build-up of brown grease-like substance, and yellow food-like particle on the underside plate overhanging the mixer bowl. The same underside plate had embedded grease and food-like particle around the perimeter of the underside plate. V8, DM stated I (V8, DM) can see the mixer has obviously not been cleaned very well after they ( kitchen staff) use it. There is a potential for cross-contamination. The facility policy Cleaning Rotation dated 2020 documents the following: Equipment and utensils will be cleansed and sanitized according to the following guidelines, or manufacturer's instruction. The same facility policy documents the procedure for cleaning and sanitization is to be completed after each use of the can opener and mixer. The facility Resident Census and Condition of Residents Form dated 7/25/23 documents 78 residents reside at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145930 If continuation sheet Page 9 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Pontiac Nursing Home 1225 South Ewing Drive Pontiac, IL 61764 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to operationalize their Infection Prevention and Control Program by failing to track infections, conduct infection surveillance, and review their policy annually. This failure has the potential to affect all 78 residents residing at the facility. Residents Affected - Many Findings Include: The facility policy Infection Prevention and Control Program dated 11/28/17 and last reviewed on 1/7/19 documents the facility is to comply with a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement. This facility has established an Infection Control Program which addressed all phases of the organization's operation to reduce or prevent the risks of nosocomial infections in residents and health care workers. The designated Infection Control employee and Quality Assurance Committee is responsible for monitoring the effectiveness of the program and continually improving outcomes. All infection control policies and procedures will be reviewed annually by the Quality Assurance Committee and revised as needed. Department Heads are responsible for assuring personnel are made aware of all revisions to respective policies and procedures. The program provides for the recording of each suspected infection and surveillance activities as they relate to individual resident infections. A log is maintained of suspected and actual infections on a day to day basis. Antibiotic use will be logged and tracked to ensure prescribing practices and outcomes are monitored for trends. The facility Infection Surveillance, Tracking and QA (Quality Assurance) Reporting Policy dated 2/14/18 documents the facility will identify, monitor, track and report infections and monitor adherence to infection control practices. Infection surveillance for compliance may include but is not limited to: review of laboratory/microbiology reports and results, observing for trends and monitoring to ensure appropriate precautions were initiated as appropriate. Infection Tracking includes but is not limited to: completing Infection Tracking Log for all residents with an infection and/or treated with antibiotics, track physician antibiotic prescribing practices as appropriate, monitor for trends by unit/location, clusters of same infection types/organisms, outbreaks, and employee illnesses. The facility's computerized Infection Control Log from August 2022 - July 2023 is incomplete with multiple missing data entries each month for the etiology of infection (if it was house acquired or if the resident admitted with the infection), type/location of infection, infectious organism, if isolation was required or not, and date the infection was resolved. On 7/26/23 at 12:58 PM, V2 DON (Director of Nursing) stated the facility does not have any infection tracking, trending or infection surveillance but there should be. V2 also confirmed the Infection Control Log is not accurate and has missing pertinent information that is required. On 07/26/23 at 1:56 PM, V1 Administrator in Training confirmed the provided policy is the most recent and current Infection Prevention and Control Program Policy. V1 confirmed the policy was last reviewed on 01/7/19 and stated the company has a team that reviews policies whenever there is a concern with the policy and explained there has been additions to the Program with COVID-19 {Highly contagious infection} but that is all in a policy of its own. On 7/26/23 at 4:38 PM, V1 stated, V13, Nurse Consultant has different Infection Control Logs, that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145930 If continuation sheet Page 10 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Pontiac Nursing Home 1225 South Ewing Drive Pontiac, IL 61764 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many include tracking, trending and surveillance of infections that was completed by V13, but they are with V13 in Chicago, not at the facility. On 7/27/23 at 8:13 AM, V1 provided the Infection Control documentation that does include trending and infection surveillance however, remains incomplete with missing data entries for ordered antibiotics, type/location of infection, infectious organism, and if isolation was required or not. The facility Anti-Infection Drug Utilization Report dated 7/26/23 documents Erythromycin {Antibiotic} 5 mg (milligrams)/gm (gram) ointment was ordered on 6/3/23 for R17, Amoxicillin 500 mg was ordered on 6/19/23 for R24, and Amoxicillin with Clavulanic Acid 875-125 mg was ordered on 6/2/23 for R75 and none of these are documented on the June 2023 Infection Control Log. On 7/27/23 at 9:44 AM, V2 DON (Director of Nursing) confirmed V2 is the acting IP (Infection Preventionist) due to V3, IP being off work on medical leave. V2 stated even though (V13, Nurse Consultant) has been doing the antibiotic tracking log, summary and trending of infections, I (V2, DON) have never seen those reports. V2 also stated V2 has not reviewed the Infection Control information or surveillance information or did anything with the information. V2 also confirmed that the June 2023 Infection Control Log is not accurate as it has missing information, therefore the trending and infection surveillance is not accurate either. The facility Resident Census and Condition of Residents Form dated 7/25/23 documents 78 residents reside at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145930 If continuation sheet Page 11 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Pontiac Nursing Home 1225 South Ewing Drive Pontiac, IL 61764 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0882 Level of Harm - Minimal harm or potential for actual harm Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review, the facility failed to have an Infection Preventionist. This failure has the potential to affect all 78 residents residing at the facility. Residents Affected - Many Findings include: On 7/26/23 at 9:38 AM, V1 Administrator in Training stated V3 is the facility IP (Infection Preventionist) however V3 has been off work for a couple of months and is on FMLA (Family Medical Leave Act) but is working some remotely on reporting of infections. On 7/26/23 at 2:41 PM, V1 stated V1 is not able to find V3's IP certificate of training but since V3 is off of work, V2 DON (Director of Nursing) is covering as IP and provided V2's certificate of training, dated 5/21/22. On 7/26/23 at 2:44 PM, V2 confirmed V2 is working as the facility IP and has been completing the Antibiotic Stewardship information but nothing else. V2 stated V2 generally works 8-10 hours a day and only spends an hour or two a day on Infection Control. The facility Resident Census and Condition of Residents Form dated 7/25/23 documents 78 residents reside at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145930 If continuation sheet Page 12 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Pontiac Nursing Home 1225 South Ewing Drive Pontiac, IL 61764 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer immunizations according to resident wishes for two of five residents (R7 and R63) reviewed for immunizations on the sample list of 28. Residents Affected - Few Findings include: The facility Influenza and Pneumococcal Immunizations Policy dated 4/21/22 documents the facility will minimize the risk of residents acquiring, transmitting, or experiencing complications from influenza and Pneumococcal pneumonia. Each resident is offered a Pneumococcal immunization per CDC (Centers of Disease Control and Prevention) recommendations. The resident medical record includes documentation that indicates, at a minimum that the resident either received or did not receive the Pneumococcal immunization due to medical contraindications or refusal. R63's medical record documents R63 was born in 1930 and admitted to the facility on [DATE]. R63's Immunization consent dated 5/25/23 documents that R63 would like to receive the Pneumococcal Immunization. R63's ongoing Immunization History does not document that R63 has ever received the Pneumococcal Immunization. R7's medical record documents R7 was born in 1936 and admitted to the facility on [DATE]. R7's Immunization consent dated 5/11/23 documents R7 wound like to receive the Pneumococcal Immunization. R7's ongoing Immunization History does not document that R7 has ever received the Pneumococcal Immunization. On 7/27/23 at 8:32 AM, V2 DON (Director of Nursing) stated V2 does not know why R63 and R7 didn't receive the requested immunization explaining V3 IP (Infection Preventionist) was handling vaccinations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145930 If continuation sheet Page 13 of 13